Data Dictionary: Inpatients

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1 Data Dictionary: Inpatients

2 Inpatient Data Dictionary Welcome to the HES Inpatient Data Dictionary. If you have any feedback or suggestions about this document please don t hesitate to contact us [http://www.hesonline.nhs.uk/ease/servlet/contentserver?siteid=1937&categoryid=377]. About the Inpatient Data Dictionary The Hospital Episode Statistics (HES) database is made up of many data items relating to admitted patient care delivered by NHS hospitals in England. Many of these items form part of the national Commissioning Data Set (CDS), and are generated by the patient administration systems within each hospital. In addition to the CDS items, HES provides information that is derived from these. For example, the age of the patient is derived from their date of birth. These derivations assist in the production of aggregate summaries (tabulations), and also help ensure patient confidentiality. HES contains data from 1 April Over the years, there have been several changes in the specification and meaning of various data items. From April 2003, this data was available in a normalised form that makes interpretation easier. This has been achieved by modifying the values of certain items for previous years so that, where possible, they conform to contemporary standards. This issue of the Data Dictionary reflects the situation after normalisation. Copyright For more information about copyright and permission to re-use the information in this document, please contact the HES team on Published September 2010 Page 1 of 243

3 Contents Admissions...7 Admission date check flag...8 Date of admission...8 Date of decision to admit...9 Date of decision to admit check flag...9 First regular day or night admission...10 Method of admission...11 Source of admission...12 Waiting time...13 Augmented/critical care period...14 ACP sequence number...15 Augmented care location...16 Augmented care period disposal...17 Augmented care period end date...18 Augmented care period local ID...18 Augmented care period number...19 Augmented care period outcome indicator...19 Augmented care period planned indicator...20 Augmented care period source...21 Augmented care period speciality function code...22 Augmented care period start date...24 High-dependency care level...24 Intensive care level days...25 Number of augmented care periods within episode...25 Number of organ systems supported...26 Clinical...27 Date of operation...28 All Diagnosis codes...28 Cause code - 4 characters...29 Cause code - 3 characters...29 Cause code...30 Intended management...30 Main operative procedure - 3 characters...31 Main specialty...32 All Operative procedure codes...34 Operation status code...35 Patient classification...35 Post-operative duration...36 Pre-operative duration...36 Primary diagnosis - 4 characters...37 Primary diagnosis - 3 characters...37 Primary diagnosis chapter...38 Treatment specialty...39 Ambulatory Care Sensitive Condition Flag...44 Principal alcohol related diagnosis...45 Principal alcohol related fraction...45 Discharges...45 Date of discharge...46 Destination on discharge...47 Discharge date check flag...49 Discharge ready date...49 Method of discharge...50 Episodes and spells...51 Bed days within the year...52 Beginning of spell...53 Date episode ended...53 Date episode started...54 Duration of spell Published September 2010 Page 2 of 243

4 End of spell...55 Episode duration...55 Episode end date check flag...56 Episode order...57 Episode start date check flag...58 Episode status...59 Episode type...60 Hospital provider spell number...60 Ward type at start of episode...61 Geographical...62 Cancer network...63 Cancer registry...63 Census Output Area, Census Output Area, 2001 (6 character)...65 County of residence...66 Current electoral ward...68 Electoral ward in Electoral ward in Electoral ward in Government office region of residence...70 Government office region of treatment...71 Health Authority of residence...72 Health Authority of treatment...73 Local authority district...74 Local authority district in Lower Super Output Area...76 Middle Super Output Area...76 Ordnance Survey grid reference...77 Patient's health authority of residence, provided by NHS...77 Patient's Primary Care Trust of residence...78 Patient's Primary Care Trust of residence historic...78 Patient's Primary Care Trust of residence current...79 Patient's Strategic Health Authority of residence...79 Patient's Strategic Health Authority of residence - historic...80 Patient's Strategic Health Authority of residence - current...80 Primary Care Trust area of treatment...error! Bookmark not defined. Region of treatment...82 Regional Office of residence...84 Rural/Urban Indicator...86 Site code of treatment...87 Strategic Health Authority area of treatment...87 Super output area...88 Westminster parliamentary constituency...88 Healthcare Resource Groups...90 HRG version n.n (HES generated)...92 Trust derived dominant procedure...93 Trust derived HRG value...93 SUS generated HRG...94 SUS generated Core Spell HRG...95 SUS generated HRG version number...96 Version No. of Trust derived HRG...96 Maternity Anaesthetic given during labour or delivery...98 Anaesthetic given post-labour or delivery...99 Antenatal days of stay Baby sequence number Baby s age in days Birth date (baby) Birth order Birth weight Published September 2010 Page 3 of 243

5 Delivery place change reason Delivery method Delivery method derived Super output area Delivery place (actual) Delivery place (intended) First antenatal assessment date Gestation period in weeks at first antenatal assessment Length of gestation Birth status Labour / delivery onset method Mother s age at delivery Mother s date of birth Mother's data of birth check flag Neonatel level of care Number of babies Number of baby tails Number of previous pregnancies Postnatal stay Resuscitation method Sex of baby Status of person conducting delivery Well baby flag Organisation Commissioner code Commissioner code status Commissioner s Regional Office Commissioner s Strategic Health Authority Commissioning serial number Health Authority area where patient s GP was registered Primary care group Primary Care Trust area where patient s GP was registered Primary care trust of responsibility Primary care trust of responsibility - historic Primary care trust of responsibility - current Provider code Provider code - 3 character Provider code - 5 character Provider type Regional Office area where patient s GP was registered Strategic Health Authority area where patient s GP was registered Patient Administrative & legal status of patient Administrative category Admin category at start of episode Admission episode flag Age at activity date Age at end of episode Age at start of episode Age on admission Age of baby in days Date of birth - patient Date of birth check flag - patient Discharge episode flag Ethnic category Finished consultant episode flag In year flag Legal category of patient Legal status classification code at start of episode Local patient identifier NHS number Published September 2010 Page 4 of 243

6 Patient ID - HES generated (original) Patient identifier - HES generated Postcode district of patient's residence Postcode of patient Sex of patient Patient pathway Duration of elective wait Earliest reasonable date offered Organisation code (patient pathway ID issuer) Patient pathway ID RTT period start date RTT period status RTT period end dat Unique booking reference number Period of care Admission date check flag Date of admission Date of decision to admit Date of decision to admit check flag First regular day or night admission Method of admission Source of admission Waiting time Intended management Main specialty Patient classification Treatment specialty Date of discharge Destination on discharge Discharge date check flag Method of discharge Bed days within the year Beginning of spell Date episode ended Date episode started Duration of spell End of spell Episode duration Episode order Episode start date check flag Episode status Episode type Hospital provider spell number Ward type at start of episode Practitioner Code of GP practice Code of GP Practice (pseudonymised) Code of patient s registered or referring general medical practitioner Pseudonymised code of patient's registered or referring general medical practitioner Consultant code Pseudonymised consultant team code Referrer code Pseudonymised referrer code Referring organisation code Psychiatric Age at psychiatric census date Carer support indicator Date detention commenced Date detention commenced check flag Detention category Published September 2010 Page 5 of 243

7 Duration of care to psychiatric census date Duration of detention Legal group of patient Legal group of patient (psychiatric) Legal status classification Marital status (psychiatric) Mental category Psychiatric history on admission Status of patient included in psychiatric census V code indicator Ward type at psychiatric census date Socio-economic IMD Barriers to Housing and Service Domain IMD Crime Domain IMD Decile Group IMD Education Training and Skills Domain IMD Employment Deprivation Domain IMD Health and Disability Domain IMD Income affecting Children Domain IMD Income affecting Adults Domain IMD Income Domain IMD Living Environment Domain IMD Overall Rank System CDS extract date CDS version number CDS protocol identifier CDS unique identifier Combined grossing factor Coverage grossing factor Date data received by NHS wide clearing service Ethnic category (audit version) Ethnic character (audit version) NHS number status indicator Origin of primary care group Origin of primary care trust of responsibility Origin of primary care trust of responsibility - historic Origin of primary care trust of responsibility - current Patient identifier (HES generated) - basis of match Record identifier SUS loaded staging date SUS record id SUS generated spell ID Index Published September 2010 Page 6 of 243

8 Admissions Admission date check flag (adm_cfl) 8 Date of admission (admidate) 8 Date of decision to admit (elecdate) 9 Date of decision to admit check flag (elec_cfl) 9 First regular day or night admission (firstreg) 10 Method of admission (admimeth) 11 Source of admission (admisorc) 12 Waiting time (elecdur) 12 Published September 2010 Page 7 of 243

9 Admission date check flag adm_cfl Admissions 1n All years Codes in this field indicate whether the patient's admission date is valid. 0 = Valid (or missing because not required) 1 = Missing 2 = Invalid Data cleaning Not applicable (derived by rule 35) Date of admission admidate Admissions dd/mm/yyyy (Date) All years This field contains the date the patient was admitted to hospital at the start of a hospital spell. Admidate is recorded on all episodes within a spell. dd/mm/yyyy = Date null = Date not known / not applicable Data cleaning Rule 35 Published September 2010 Page 8 of 243

10 Date of decision to admit elecdate Admissions dd/mm/yyyy (Date) All years This field contains the date on which a consultant, or another member of the clinical staff, decided to admit the patient to a hospital. The patient may or may not be admitted immediately. The time between elecdate and admidate (admission date) is known as the waiting time. dd/mm/yyyy = Date null = Date not known / not applicable Data cleaning Rules 40 and 45 Date of decision to admit check flag elec_cfl Admissions 1n All years Codes in this field indicate whether the decision to admit date is valid. 0 = Valid (or missing because not required) 1 = Missing 2 = Invalid Data cleaning Not applicable: derived by Rules 40 and 45 Published September 2010 Page 9 of 243

11 First regular day or night admission firstreg Admissions 1n From This field indicates whether the episode falls within a sequence of regular day and night admissions and, if so, whether it is the first or subsequent episode within the sequence. 0 = First in a series 1 = Subsequent to first in a series 8 = Not applicable: this episode of care is neither the first nor any subsequent attendance within a sequence of regular day/night admissions 9 = Not known: this episode is an attendance within a sequence of regular day/night admissions, but the status of this episode within the attendance is not known: a validation error Data cleaning None Published September 2010 Page 10 of 243

12 Method of admission admimeth Admissions 2n All years This field contains a code which identifies how the patient was admitted to hospital. Admimeth is recorded on the first and also all subsequent episodes within the spell (ie where the spell is made up of more than one episode). 11 = Elective: from waiting list 12 = Elective: booked 13 = Elective: planned 21 = Emergency: via Accident and Emergency (A&E) services, including the casualty department of the provider 22 = Emergency: via general practitioner (GP) 23 = Emergency: via Bed Bureau, including the Central Bureau 24 = Emergency: via consultant outpatient clinic 28 = Emergency: other means, including patients who arrive via the A&E department of another healthcare provider 31 = Maternity: where the baby was delivered after the mother's admission 32 = Maternity: where the baby was delivered before the mother's admission 81 = Transfer of any admitted patient from another hospital provider other than in an emergency; this does not include admissions to high security psychiatric hospitals (HSPH) 82 = Other: babies born in health care provider 83 = Other: babies born outside the health care provider, except when born at home as intended 84 = Admission by the admission panel of an HSPH; patient not entered on the HSPH admissions waiting list (not valid for admissions after 31 March 2002) 89 = From the admissions waiting list of an HSPH (not valid for admissions after 31 March 2002) 98 = Not applicable (eg other maternity event) 99 = Not known Data cleaning Rules 65, 70 and 320 Published September 2010 Page 11 of 243

13 Source of admission admisorc Admissions 2n All years This field contains a code which identifies where the patient was immediately prior to admission. Most patients are admitted from home, but there are some significant exceptions. In particular, this field differentiates between patients admitted from home and patients transferred from another hospital provider or institution. 19 = The usual place of residence, including no fixed abode 29 = Temporary place of residence when usually resident elsewhere, for example, hotels and residential educational establishments 30 = Repatriation from high security psychiatric hospital ( to ) 37 = Penal establishment: court ( to ) 38 = Penal establishment: police station ( to ) 39 = Penal establishment (court and police station excluded from ) 48 = High security psychiatric hospital, Scotland ( to ) 49 = NHS other hospital provider: high security psychiatric accommodation in an NHS hospital provider (NHS trust) 50 = NHS other hospital provider: medium secure unit ( to ) 51 = NHS other hospital provider: ward for general patients or the younger physically disabled or A&E department 52 = NHS other hospital provider: ward for maternity patients or neonates 53 = NHS other hospital provider: ward for patients who are mentally ill or have learning disabilities 54 = NHS run nursing home, residential care home or group home 65 = Local authority Part 3 residential accommodation: where care is provided (from ) 66 = Local authority foster care, but not in Part 3 residential accommodation: where care is provided (from ) 69 = Local authority home or care ( to ) 79 = Babies born in or on the way to hospital 85 = Non-NHS (other than Local Authority) run residential care home (from ) 86 = Non-NHS (other than Local Authority) run nursing home (from to ) 87 = Non-NHS run hospital 88 = non-nhs (other than Local Authority) run hospice 89 = Non-NHS institution ( to ) 98 = Not applicable 99 = Not known Data cleaning Rule 80 Published September 2010 Page 12 of 243

14 Waiting time elecdur Admissions 4n This derived field contains the difference in days between the date on which it was decided to admit the patient (elecdate) and the actual admission date (admidate). Elecdur is only applicable where an elective admission (ie the admission method is 11, 12 or 13) was scheduled and took place. 4n = Waiting time in days from 1 to 8887 null = Other maternity events / not known Data cleaning Not applicable (derived by rule 270) Published September 2010 Page 13 of 243

15 Augmented/critical care period ACP sequence number (acpseq) 14 Augmented care location (acploc) 16 Augmented care period disposal (acpdisp) 17 Augmented care period end date (acpend) 18 Augmented care period local ID (acplcid) 18 Augmented care period number (acpn) 19 Augmented care period outcome indicator (acpout) 19 Augmented care period planned indicator (acpplan) 20 Augmented care period source (acpsour) 21 Augmented care period speciality function code (acpspef) 22 Augmented care period start date (acpstar) 24 High-dependency care level (depdays) 24 Intensive care level days (intdays) 25 Number of augmented care periods within episode (numacp) 25 Number of organ systems supported (orgsup) 26 Published September 2010 Page 14 of 243

16 ACP sequence number acpseq Augmented/critical care period 1n From 1 October 1997 to 31 March 2006 Augmented care period sequence number. n = ACP sequence number Data cleaning None Published September 2010 Page 15 of 243

17 Augmented care location acploc Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field gives the location of a patient during a period of augmented care. 01 = General intensive care unit (ICU). Adult intensive care, including wards labelled as surgical or medical ICU, but excluding the specialised units identified by other values. General ICUs may provide a mixture of high dependency unit (HDU) and ICU level care. 02 = Cardiothoracic ICU, including units labelled as separate cardiac or thoracic units. 03 = Liver ICU 04 = Neurological ICU 05 = HDU 06 = Paediatric ICU: a unit generally admitting patients between 0 and 14 years old, but excluding special care baby units 07 = Paediatric HDU 08 = Neonatal ICU: a unit generally admitting only new born babies up to two-week's post delivery 09 = Cardiac care unit or coronary care unit (CCU) 10 = Combined HDU and CCU the beds and staff for the two units are in the same area 11 = Combined CCU and ICU the beds and staff for the two units are in the same area 12 = Combined HDU and ICU the beds and staff for the two units are in the same area 13 = Post operative recovery unit, including a theatre recovery area 14 = Spinal injury ICU: a unit designated for critical care rather than a spinal injury ward 15 = Burns critical care unit, including all special care burns facilities other than short-term post-operative care areas 16 = Renal unit, including an in-patient kidney dialysis unit, but excluding general nephrology or urology wards 17 = Not otherwise specified 99 = Not known Data cleaning Rules 950 and 960 Published September 2010 Page 16 of 243

18 Augmented care period disposal acpdisp Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field gives the destination of a discharged patient after a period of augmented care. Compare this field with disdest (destination on discharge from a hospital episode). 01 = Ward in same hospital 02 = High dependency unit (HDU) in same hospital, including special care baby units 03 = Intensive care unit (ICU) in same hospital 04 = ICU in other hospital 05 = Other hospital (not ICU) including HDUs and Special Care Baby Units 06 = Normal residence or other 07 = Died 08 = No change in location: the augmented care period ended because the consultant episode ended 98 = Not applicable: augmented care period not finished 99 = Not known Data cleaning Rules 920 and 930 Published September 2010 Page 17 of 243

19 Augmented care period end date acpend Augmented/critical care period dd/mm/yyyy (Date) From 1 October 1997 to 31 March 2006 This field gives the end date of a period of augmented care (a null entry indicates that this data is not applicable). dd/mm/yyyy = Date augmented care period ended Data cleaning Rule 940 Augmented care period local ID acplcid Augmented/critical care period 8an From to 31 March 2006 There are no nationally agreed values for this item. This field contains sensitive data. Access to it requires the approval of the Database Monitoring Sub-Group (DMSG). Not available Data cleaning None Published September 2010 Page 18 of 243

20 Augmented care period number acpn Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field contains a number representing the order of an episode within a sequence of episodes that make up a period of augmented care. 2n = Order number in the range 01 to = Not known: a validation error Data cleaning Rule 970 Augmented care period outcome indicator acpout Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field identifies whether a patient survived. For deaths it indicates whether organs were donated. Organs are defined as whole organs such as heart, lung, liver, kidney and pancreas. The value 03 does not include parts of organs such as corneas, heart valves, etc. 01 = Survived 02 = Died: no organ donation 03 = Died: organs donated 98 = Not applicable: Augmented care period not finished 99 = Not known Data cleaning Rule 980 and Rule 990 Published September 2010 Page 19 of 243

21 Augmented care period planned indicator acpplan Augmented/critical care period 1n From 1 October 1997 to 31 March 2006 This field indicates whether any part of the ACP was planned in advance of admission to the ACP location. 1 = Yes 2 = No 9 = Not known Data cleaning Rule Published September 2010 Page 20 of 243

22 Augmented care period source acpsour Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field defines where the patient was immediately before the period of augmented care. Compare this field with admisorc (source of patient for a hospital episode). 01 = Ward in same hospital 02 = High dependency unit (HDU) or other immediate care area in same hospital, including special care babies 03 = Intensive care unit (ICU) in same hospital 04 = Theatre or recovery unit in same hospital 05 = A&E department in same hospital 06 = X-ray or endoscopy department in same hospital 07 = ICU in other hospital 08 = Other hospital (not ICU) including HDUs and special care baby units 09 = Clinic, home or other 10 = No change in location: augmented care period started because consultant episode changed 99 = Not known Data cleaning Rule 900 and Rule 910 Published September 2010 Page 21 of 243

23 Augmented care period speciality function code acpspef Augmented/critical care period 3n From 1 October 1997 to 31 March 2006 This field contains the code for the main specialty of the consultant clinically managing the period of augmented care. This consultant is not necessarily the same as the one responsible for the hospital episode. Where a patient is cared for by a team of specialists within an Intensive Care rota, this field contains the specialty of the team's clinical director. Where there are several specialties involved but none is considered responsible, this field contains the specialty of the consultant admitting the patient to the period of augmented care. If no specific consultant or team can be identified as organising the care associated with the ACP, then this should be the same as for the related consultant episode. 100 = General surgery 101 = Urology 110 = Trauma and orthopaedics 120 = Ear, nose and throat (ENT) 130 = Ophthalmology 140 = Oral surgery 141 = Restorative dentistry 142 = Paediatric dentistry (available from ) 143 = Orthodontics 145 = Oral and maxillo facial surgery (available from ) 146 = Endodontics (available from ) 147 = Periodontics (available from ) 148 = Prosthodontics (available from ) 149 = Surgical dentistry (available from ) 150 = Neurosurgery 160 = Plastic surgery 170 = Cardiothoracic surgery 171 = Paediatric surgery 180 = Accident and emergency (A&E) 190 = Anaesthetics 191 = Pain management (available from to ) 192 = Critical care medicine (available from ) 199 = Non-UK Provider - specialty function not known, treatment mainly surgical 300 = General medicine 301 = Gastroenterology 302 = Endocrinology 303 = Clinical haemotology 304 = Clinical physiology 305 = Clinical pharmacology 310 = Audiological medicine 311 = Clinical genetics 312 = Clinical cytogenics and molecular genetics (available from ) Published September 2010 Page 22 of 243

24 313 = Clinical immunology and allergy (available from ) 314 = Rehabilitation (available from ) 315 = Palliative medicine 320 = Cardiology 321 = Paediatric cardiology (available from ) 330 = Dermatology 340 = Respiratory medicine (also known as thoracic medicine) 350 = Infectious diseases 352 = Tropical medicine (available from ) 360 = Genito-urinary medicine 361 = Nephrology 370 = Medical oncology 371 = Nuclear medicine 400 = Neurology 401 = Clinical neuro-physiology 410 = Rheumatology 420 = Paediatrics 421 = Paediatric neurology 430 = Geriatric medicine 450 = Dental medicine (available from ) 460 = Medical opthalmology (available from ) 499 = Non-UK Provider - specialty function not known, treatment mainly medical 501 = Obstetrics (prior to : Obstetrics for patients using a hospital bed or delivery facilities) 502 = Gynaecology 560 = Midwifery (available from October 1995) 600 = General Medical Practice 601 = General Dental Practice 610 = General practice with maternity function (available to ) 620 = General practice other than maternity (available to ) 700 = Learning disability (previously known as mental handicap) 710 = Mental illness 711 = Child and adolescent psychiatry 712 = Forensic psychiatry 713 = Psychotherapy 715 = Old age psychiatry (available from ) 800 = Clinical oncology (previously Radiotherapy) 810 = Radiology 820 = General pathology 821 = Blood transfusion 822 = Chemical pathology 823 = Haematology 824 = Histopathology 830 = Immunopathology 831 = Medical microbiology 832 = Neuropathology (available to ) 900 = Community medicine 901 = Occupational medicine 902 = Community health services - dental (available from ) 903 = Public health medicine (available from ) 904 = Public health dental (available from ) 950 = Nursing episode (available from ) 960 = Allied health professional episode (available from ) null = Other maternity event & = Not known Data cleaning Rule Published September 2010 Page 23 of 243

25 Augmented care period start date acpstar Augmented/critical care period dd/mm/yyyy = Date From 1 October 1997 to 31 March 2006 This field states the start date of a period of augmented care. dd/mm/yyyy = Date period started null = Not applicable / not known Data cleaning Rule 1020 High-dependency care level depdays Augmented/critical care period 4n From 1 October 1997 to 31 March 2006 This field contains the number of days of high dependency care in a period of augmented care. 4n = Number of days in the range 000 to = Not known: a validation error Data cleaning Rule Published September 2010 Page 24 of 243

26 Intensive care level days intdays Augmented/critical care period 4n From 1 October 1997 to 31 March 2006 This field contains the number of days of intensive care in a period of augmented care. 4n = Number of days in the range 0000 to 9998 null = Not known: a validation error Data cleaning Rule 1040 Number of augmented care periods within episode numacp Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This derived field gives the number of augmented care periods (ACPs) within episode. 2n = Number of augmented care periods within the episode Data cleaning Not applicable (derived by rule 1060) Published September 2010 Page 25 of 243

27 Number of organ systems supported orgsup Augmented/critical care period 2n From 1 October 1997 to 31 March 2006 This field contains the number of organ support systems used (up to five) during a period of augmented care. 2n = Number of organ systems supported in the range 00 to = Not applicable: Augmented care period not finished 99 = Not known: a validation error Data cleaning Rule Published September 2010 Page 26 of 243

28 Clinical Date of operation (opdte_nn) 28 All Diagnosis codes (diag_nn) 28 Cause code - 4 characters (cause4dg) 29 Cause code - 3 characters (cause3dg) 29 Cause code (cause) 30 Intended management (intmanig) 30 Main operative procedure - 3 characters (oper3) 31 Main specialty (mainspef) 32 All Operative procedure codes (oper_nn) 34 Operation status code (operstat) 35 Patient classification (classpat) 35 Post-operative duration (posopdur) 36 Pre-operative duration (preopdur) 36 Primary diagnosis - 4 characters (diag4) 37 Primary diagnosis - 3 characters (diag3) 37 Primary diagnosis chapter (chapter) 38 Treatment specialty (tretspef) 39 Ambulatory Care Sensitive Condition Flag ( Acscflag) 44 Principal alcohol related diagnosis (Alcdiag) 45 Principal alcohol related fraction (Alcfrac) 45 Published September 2010 Page 27 of 243

29 Date of operation opdte_nn Clinical dd/mm/yyyy (Date) This field contains the dates for operations recorded in the operation codes (oper_nn) field. There is room for twenty-four dates (twelve prior to April 2002). dd/mm/yyyy = Date of operation Data cleaning Rules 480, 485, 610 and 620 All diagnosis codes diag_nn Clinical 6an There are twenty fields (fourteen before April 2007 and seven before April 2002), diag_01 to diag_20, which contain information about a patient's illness or condition. The field diag_01 contains the primary diagnosis. The other fields contain secondary/subsidiary diagnoses. The codes are defined in the International Statistical ification of Diseases, Injuries and Causes of Death. HES records currently use the tenth revision (ICD-10). Prior to April 1995, the ninth revision was used (ICD-9). Diagnosis codes start with a letter and are followed by two or three digits. The third digit identifies variations on a main diagnosis code containing two digits. The third digit is preceded by a full stop in ICD-10, but this is not stored in the field. annnna = A valid ICD-9 or ICD-10 diagnosis code annnnn = A valid ICD-9 or ICD-10 diagnosis code null = not applicable Data cleaning Rules 460, 470, 490, 500, 510, 530, 630, 640, 840 and 850 Published September 2010 Page 28 of 243

30 Cause code - 4 characters cause4dg Clinical 4an This item is a copy of the initial 4 characters of the first diagnosis code that represents an external cause, eg accidents or poisoning. 4an = Code copied from a diagnosis field: this is a standard ICD-10 code in the range V01-Y98 null = Unfinished episode, other maternity event or no cause code found Data cleaning Rules 460, 470, 510 and 530 (then derived by rule 580) Cause code - 3 characters cause3 Clinical 3an This item is a copy of the initial 3 characters of the first diagnosis code that represents an external cause, eg accidents or poisoning. 3an = Code copied from a diagnosis field: this is a standard ICD-10 code in the range V01-Y98 null = Unfinished episode, other maternity event or no cause code found Data cleaning Rules 460, 470, 510 and 530 (then derived by rule 580) Published September 2010 Page 29 of 243

31 Cause code cause Clinical 6an External cause of injury or poisoning. This item is a copy of the first diagnosis code that represents an external cause. 6an = Code copied from a diagnosis field: this is a standard ICD-10 code in the range V01-Y98 null = Unfinished episode, other maternity event or no cause code found Data cleaning Rules 460, 470, 510 and 530 (then derived by rule 580) Intended management intmanig Clinical 1n From This field contains a code that defines what was planned to happen. The patient classification (classpat) defines what actually happened. 1 = Patient to stay in hospital for at least one night 2 = Patient not to stay in hospital overnight 3 = Patient to have a planned series of admissionsat least one overnight stay 4 = Patient to have a planned sequence of admissions no overnight stay 5 = Patient to be admitted regularly for a sequence of nights rest of the 24 hour period at home 8 = Not applicable 9 = Not known Data cleaning Rule 120 Published September 2010 Page 30 of 243

32 Main operative procedure - 3 characters oper3 Clinical 3an, - or & This provides the first three characters of the main operation (oper_1). 3an = Procedure code - = No operation performed & = Not known Data cleaning Not applicable (this item is derived from a cleaned field) Published September 2010 Page 31 of 243

33 Main specialty mainspef Clinical 3n or & This field contains a code that defines the specialty under which the consultant is contracted. It can be compared with tretspef, the specialty under which the consultant worked. 100 = General surgery 101 = Urology 110 = Trauma and orthopaedics 120 = Ear, nose and throat (ENT) 130 = Ophthalmology 140 = Oral surgery 141 = Restorative dentistry 142 = Paediatric dentistry (available from ) 143 = Orthodontics 145 = Oral and maxillo facial surgery (available from ) 146 = Endodontics (available from ) 147 = Periodontics (available from ) 148 = Prosthodontics (available from ) 149 = Surgical dentistry (available from ) 150 = Neurosurgery 160 = Plastic surgery 170 = Cardiothoracic surgery 171 = Paediatric surgery 180 = Accident and emergency (A&E) 190 = Anaesthetics 191 = Pain management (available from to ) 192 = Critical care medicine (available from ) 199 = Non-UK Provider - specialty function not known, treatment mainly surgical 300 = General medicine 301 = Gastroenterology 302 = Endocrinology 303 = Clinical haemotology 304 = Clinical physiology 305 = Clinical pharmacology 310 = Audiological medicine 311 = Clinical genetics 312 = Clinical cytogenics and molecular genetics (available from ) 313 = Clinical immunology and allergy (available from ) 314 = Rehabilitation (available from ) 315 = Palliative medicine 320 = Cardiology 321 = Paediatric cardiology (available from ) 330 = Dermatology 340 = Respiratory medicine (also known as thoracic medicine) 350 = Infectious diseases 352 = Tropical medicine (available from ) Published September 2010 Page 32 of 243

34 360 = Genito-urinary medicine 361 = Nephrology 370 = Medical oncology 371 = Nuclear medicine 400 = Neurology 401 = Clinical neuro-physiology 410 = Rheumatology 420 = Paediatrics 421 = Paediatric neurology 430 = Geriatric medicine 450 = Dental medicine (available from ) 460 = Medical opthalmology (available from ) 499 = Non-UK Provider - specialty function not known, treatment mainly medical 501 = Obstetrics (prior to : Obstetrics for patients using a hospital bed or delivery facilities) 502 = Gynaecology 560 = Midwifery (available from October 1995) 600 = General Medical Practice 601 = General Dental Practice 610 = General practice with maternity function (available to ) 620 = General practice other than maternity (available to ) 700 = Learning disability (previously known as mental handicap) 710 = Adult mental illness 711 = Child and adolescent psychiatry 712 = Forensic psychiatry 713 = Psychotherapy 715 = Old age psychiatry (available from ) 800 = Clinical oncology (previously Radiotherapy) 810 = Radiology 820 = General pathology 821 = Blood transfusion 822 = Chemical pathology 823 = Haematology 824 = Histopathology 830 = Immunopathology 831 = Medical microbiology 832 = Neuropathology (available to ) 900 = Community medicine 901 = Occupational medicine 902 = Community health services - dental (available from ) 903 = Public health medicine (available from ) 904 = Public health dental (available from ) 950 = Nursing episode (available from ) 960 = Allied health professional episode (available from ) null = Other maternity event & = Not known Data cleaning Rule 90 and Rule 350 Published September 2010 Page 33 of 243

35 All operative procedure codes oper_nn Clinical 4an, - or & There are twenty-four fields (twelve before April 2007 and four prior to April 2002), oper_01 to oper_24, which contain information about a patient's operations. The field oper_01 contains the main (ie most resource intensive) procedure. The other fields contain secondary procedures. The codes are defined in the Tabular List of the ification of Surgical Operations and Procedures. The current version is OPCS4. Procedure codes start with a letter and are followed by two or three digits. The third digit identifies variations on a main procedure code containing two digits. The third digit is preceded by a full stop in OPCS4, but this is not stored in the field. A single operation may contain more than one procedure. 4an = Procedure code - = No operation performed & = Not known Data cleaning Rules 450, 540, 550, 560, 610 and 620 Published September 2010 Page 34 of 243

36 Operation status code operstat Clinical 1n From Status of operation. 1 = One or more operative procedures carried out 8 = Not applicable, ie no operative procedures performed or intended 9 = Not known, ie finished episode but no data entered or the episode is unfinished and no data needs to be present. (This would only be a validation error for a finished episode.) Data cleaning None Patient classification classpat Clinical 1n This field identifies day cases, ordinary admissions, regular day and regular night attenders, and the special case of mothers and babies using only delivery facilities. Data about regular day and regular night attenders are not available for analysis prior to Since the introduction of the NHS wide clearing service in April 1996, this field has been derived from related items in the Commissioning Data Set (eg intended management). 1 = Ordinary admission 2 = Day case admission 3 = Regular day attender 4 = Regular night attender 5 = Mothers and babies using only delivery facilities 8 = Not applicable (other maternity event) Data cleaning Not applicable (derived by rule 260) Published September 2010 Page 35 of 243

37 Post-operative duration posopdur Clinical 3n This derived field contains the difference in days between the date of the main operation (opdte_01) and the date the episode ended (epiend). 3n = Number of days between the main operation and the end of the episode from null = Not applicable: no operation or episode unfinished Data cleaning Not applicable (derived by rule 1070) Pre-operative duration preopdur Clinical 3n This derived field contains the difference in days between the date the episode started (epistart) and the date of the main operation (opdte_01). 3n = Number of days between the start of the episode and the main operation from null = Not applicable: no operation or episode unfinished Data cleaning Not applicable (derived by rule 1075) Published September 2010 Page 36 of 243

38 Primary diagnosis - 4 characters diag4 Clinical 4an This provides the first four characters of the primary diagnosis (diag_01). 4an = A valid ICD-9 or ICD-10 diagnosis code null = Not applicable Data cleaning Not applicable (derived from a cleaned field) Primary diagnosis - 3 characters diag3 Clinical 3an This provides the first three characters of the primary diagnosis (diag_01). 3an = A valid ICD-9 or ICD-10 diagnosis code null = Not applicable Data cleaning Not applicable (derived from a cleaned field) Published September 2010 Page 37 of 243

39 Primary diagnosis chapter chapter Clinical 4an This provides the chapter of the primary diagnosis (diag_01). Chapters I to XXII Data cleaning Published September 2010 Page 38 of 243

40 Treatment specialty tretspef Clinical 3n or & This field contains a code that defines the specialty in which the consultant was working during the period of care. It can be compared with mainspef, the specialty under which the consultant is contracted. Prior to 1 April 1996, this data item contained the code for the sub-specialty (subspef). From April 2004 a new list of treatment specialities was introduced (see below). The new list describes the specialised service within which the patient was treated. From 1 April 2004: 100 = General surgery 101 = Urology 102 = Transplantation surgery (includes renal and liver transplants, excludes cardiothoracic transplantation) 103 = Breast surgery (includes suspected neoplasms, cysts etc, does not include cosmetic surgery) 104 = Colorectal surgery (surgical treatment of disorders of the lower intestine - colon, anus and rectum) 105 = Hepatobiliary & pancreatic surgery (includes liver surgery but excludes liver transplantation see transplantation surgery) 106 = Upper gastrointestinal surgery 107 = Vascular surgery 110 = Trauma & orthopaedics 120 = Ear, nose and throat (ENT) 130 = Ophthalmology 140 = Oral surgery 141 = Restorative dentistry (endodontics, periodontics and prosthodontics) 142 = Paediatric dentistry 143 = Orthodontics 144 = Maxillo-facial surgery 150 = Neurosurgery 160 = Plastic surgery 161 = Burns care (recognised specialist services only - includes 'outreach' facilities) 170 = Cardiothoracic surgery (where there are no separate services for cardiac and thoracic surgery) 171 = Paediatric surgery 172 = Cardiac surgery 173 = Thoracic surgery 174 = Cardiothoracic transplantation (recognised specialist services only - includes 'outreach' facilities) 180 = Accident & emergency (A&E) 190 = Not a treatment function 191 = Pain management (complex pain disorders requiring diagnosis and treatment by a specialist multi-professional team) 192 = Critical care medicine (also known as intensive care medicine) Published September 2010 Page 39 of 243

41 199 = Non-UK Provider - specialty function not known, treatment mainly surgical 211 = Paediatric Urology (from ) 212 = Paediatric Transplantation Surgery (from ) 213 = Paediatric Gastrointestinal Surgery (from ) 214 = Paediatric Trauma and Orthopaedics (from ) 215 = Paediatric Ear Nose and Throat (from ) 216 = Paediatric Ophthalmology (from ) 217 = Paediatric Maxillo-Facial Surgery (from ) 218 = Paediatric Neurosurgery (from ) 219 = Paediatric Plastic Surgery (from ) 220 = Paediatric Burns Care (from ) 221 = Paediatric Cardiac Surgery (from ) 222 = Paediatric Thoracic Surgery (from ) 241 = Paediatric Pain Management (from ) 242 = Paediatric Intensive Care (from ) 251 = Paediatric Gastroenterology (from ) 252 = Paediatric Endocrinology (from ) 253 = Paediatric Clinical Haetology (from ) 254 = Paediatric Audiological Medicine (from ) 255 = Paediatric Clinical Immunology and Allergy (from ) 256 = Paediatric Infectious diseases (from ) 257 = Paediatric Dermatology (from ) 258 = Paediatric Respiratory Medicine (from ) 259 = Paediatric Nephrology (from ) 260 = Paediatric Medical Oncology (from ) 261 = Paediatric Metabolic disease (from ) 262 = Paediatric Pheumalogy (from ) 280 = Paediatric Interventional Radiology (from ) 290 = Community Paediatrics (from ) 291 = Paediatric Neuro-disability (from ) 300 = General medicine 301 = Gastroenterology 302 = Endocrinology 303 = Clinical haematology 304 = Clinical Physiology (from ) 305 = Clinical pharmacology 306 = Hepatology 307 = Diabetic medicine 308 = Bone and marrow transplantation (previously part of clinical haematology) 309 = Haemophilia (previously part of clinical haematology) 310 = Audiological medicine 311 = Clinical genetics 312 = Not a treatment function 313 = Clinical immunology and allergy (where there are no separate services for clinical immunology and allergy) 314 = Rehabilitation 315 = Palliative medicine 316 = Clinical immunology 317 = Allergy 318 = Intermediate care (encompasses a range of multidisciplinary services designed to safeguard independence by maximising rehabilitation and recovery) 319 = Respite care 320 = Cardiology 321 = Paediatric cardiology 322 = Clinical microbiology 323 = Spinal Injuries (from ) 330 = Dermatology 340 = Thoracic medicine 341 = Respiratory Physiology (previously known as Sleep studies) 350 = Infectious diseases Published September 2010 Page 40 of 243

42 352 = Tropical medicine 360 = Genito-urinary medicine 361 = Nephrology 370 = Medical oncology 371 = Nuclear Medicine (from ) 400 = Neurology 401 = Clinical Neurophysiology (from ) 410 = Rheumatology 420 = Paediatrics 421 = Paediatric neurology 422 = Neonatology 424 = Well babies (care given by the mother/substitute, with nursing advice if needed) 430 = Geriatric medicine 450 = Dental medicine 460 = Medical ophthalmology 499 = Non-UK Provider - specialty function not known, treatment mainly medical 500 = Not a treatment function 501 = Obstetrics 502 = Gynaecology 503 = Gynaecological oncology 510 and 520 = Not treatment functions 560 = Midwife episode 600, 610 and 620 = Not treatment functions 650 = Physiotherapy (from ) 651 = Occupational Therapy (from ) 652 = Speech and Language Therapy (from ) 653 = Podiatry (from ) 654 = Dietetics (from ) 655= Orthoptics (from ) 656 = Clinical Psychology (from ) 700 = Learning disability (previously known as mental handicap) 710 = Adult mental illness 711 = Child and adolescent psychiatry 712 = Forensic psychiatry 713 = Psychotherapy 715 = Old age psychiatry 720 = Eating Disorders (from ) 721 = Addicition Services (from ) 722 = Liaison Psychiatry (from ) 723 = Psychiatric Intensive Care(from ) 724 = Perinatal Psychiatry (from ) 800 = Clinical oncology (previously known as Radiotherapy) 810 = Radiology (until ) 811 = Interventional radiology 812 = Diagnostic Imaging (from ) 820 and 821 = Not treatment functions 822 = Chemical pathology 823, 824, 830, , 900, 901, 950 and 990 = Not treatment functions 840 = Audiology (from ) null = Other maternity event & = Not known Until 31 March 2004: 100 = General surgery 101 = Urology 110 = Trauma and orthopaedics 120 = Ear, nose and throat (ENT) 130 = Ophthalmology 140 = Oral surgery Published September 2010 Page 41 of 243

43 141 = Restorative dentistry 142 = Paediatric dentistry (from ) 143 = Orthodontics 150 = Neurosurgery 160 = Plastic surgery 170 = Cardiothoracic surgery 171 = Paediatric surgery 180 = Accident and emergency (A&E) 190 = Anaesthetics 191 = Pain management (from ) 300 = General medicine 301 = Gastroenterology 302 = Endocrinology 303 = Haematology (clinical) 304 = Clinical physiology 305 = Clinical pharmacology 310 = Audiological medicine 311 = Clinical genetics 312 = Clinical cytogenics and molecular genetics (from ) 313 = Clinical immunology and allergy (from ) 314 = Rehabilitation (from ) 315 = Palliative medicine 320 = Cardiology 330 = Dermatology 340 = Thoracic medicine 350 = Infectious diseases 360 = Genito-urinary medicine 361 = Nephrology 370 = Medical oncology 371 = Nuclear medicine 400 = Neurology 401 = Clinical neuro-physiology 410 = Rheumatology 420 = Paediatrics 421 = Paediatric neurology 430 = Geriatric medicine 450 = Dental medicine (from ) 460 = Medical opthalmology (from ) 501 = Obstetrics for patients using a hospital bed or delivery facilities 502 = Gynaecology 560 = Midwifery (from October 1995) 610 = General practice with maternity function 620 = General practice other than maternity 700 = Learning disability (previously known as mental handicap) 710 = Mental illness 711 = Child and adolescent psychiatry 712 = Forensic psychiatry 713 = Psychotherapy 715 = Old age psychiatry (from ) 800 = Clinical oncology (previously known as Radiotherapy) 810 = Radiology 820 = General pathology 821 = Blood transfusion 822 = Chemical pathology 823 = Haematology 824 = Histopathology 830 = Immunopathology 831 = Medical microbiology 832 = Neuropathology 900 = Community medicine Published September 2010 Page 42 of 243

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